Department of Obstetrics, Leiden University Medical Center, Leiden, The Netherlands.
Port-Royal Maternity Unit, Cochin hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
Acta Obstet Gynecol Scand. 2024 Sep;103(9):1877-1887. doi: 10.1111/aogs.14917. Epub 2024 Jul 18.
Obstetric hemorrhage remains a largely preventable cause of maternal mortality globally. The contribution of uterine atony to hemorrhage-related maternal mortality has decreased in France, while the contribution of other causes of obstetric hemorrhage such as surgical injury during cesarean has been reported to increase. However, little evidence exists regarding the risk factors and care processes of women who died from this cause of hemorrhage. Therefore, we aimed to describe the clinical profile, underlying mechanisms, and preventability factors among women who died from obstetric hemorrhage by surgical injury during cesarean section.
Nationwide analysis of all hemorrhage-related maternal deaths by surgical injury during cesarean in France identified by the nationwide permanent enhanced maternal mortality surveillance system (ENCMM) between 2007 and 2018. We described the characteristics of the women, delivery hospitals, circumstances of hemorrhage, features of obstetric and resuscitation/transfusion care, and main preventability factors.
Between 2007 and 2018, hemorrhage-related maternal mortality in France decreased from 1.6/100 000 live births (95% CI 1.1-2.2) (39/2 472 650) in 2007-2009 to 0.8/100 000 live births (95% CI 0.5-1.3) (19/2 311 783) in 2016-2018. Hemorrhage-related maternal mortality ratio due to surgical injury during cesarean increased from 0.08 (95% CI 0.01-0.3) (2/2 472 650) to 0.2 (95% CI 0.07-0.5) (5/2 311 783) per 100 000 live births. Among the 18 women who died from surgical injury during cesarean over the 12-year study period, we report a high prevalence of obesity (67%, 12/18), previous cesarean (72%, 13/18), and second-stage cesareans (56%, 10/18). In 22% (4/18), cesarean section was performed in a hospital providing <1000 births annually, with no blood bank (39%, 7/18) or no adult intensive care (44%, 8/18) on-site. Overall preventability of deaths was 94% (17/18). Main preventability factors were related to delay in hemorrhage diagnosis (77%, 14/18) due to late recognition of abnormal parameters (33%, 6/18) and late bedside ultrasound (56%, 10/18), and delay in management due to insufficient surgical skills (56%, 10/18).
In France, surgical injury during cesarean section is an increasing, largely preventable contributor to hemorrhage-related maternal mortality, as other causes of fatal hemorrhage have become less frequent. The profile of these women showed a high prevalence of obesity, previous cesarean, second-stage cesarean, and delivery in hospitals with limited medical and surgical resources, which suggests explanatory mechanisms for the fatal outcome and opportunities for prevention.
产科出血仍然是全球范围内导致产妇死亡的一个主要可预防原因。在法国，由于子宫收缩乏力导致的出血相关产妇死亡率有所下降，而剖宫产术中外科损伤等其他产科出血原因的死亡率则有所上升。然而，关于因外科损伤导致出血而死亡的妇女的风险因素和护理过程的证据很少。因此，我们旨在描述法国因剖宫产术中外科损伤导致出血死亡的妇女的临床特征、潜在机制和可预防因素。
通过全国永久性增强孕产妇死亡率监测系统（ENCMM）对法国 2007 年至 2018 年期间所有因剖宫产术中外科损伤导致的出血相关孕产妇死亡病例进行了全国性分析。我们描述了妇女、分娩医院、出血情况、产科和复苏/输血护理的特征，以及主要的可预防因素。
2007 年至 2018 年，法国因剖宫产术中外科损伤导致的出血相关孕产妇死亡率从 2007-2009 年的每 10 万活产 1.6/100000（95%CI 1.1-2.2）（39/2472650）降至 2016-2018 年的每 10 万活产 0.8/100000（95%CI 0.5-1.3）（19/2311783）。因剖宫产术中外科损伤导致的出血相关孕产妇死亡率比从 0.08（95%CI 0.01-0.3）（2/2472650）增加到 0.2（95%CI 0.07-0.5）（5/2311783）每 10 万活产。在 12 年研究期间，因剖宫产术中外科损伤而死亡的 18 名妇女中，我们报告了肥胖症的高发率（67%，12/18）、既往剖宫产史（72%，13/18）和第二产程剖宫产（56%，10/18）。在 22%（4/18）的情况下，剖宫产在每年分娩量低于 1000 例的医院进行，这些医院没有血库（39%，7/18）或没有成人重症监护病房（44%，8/18）。总体死亡率可预防率为 94%（17/18）。主要的可预防因素与出血诊断延迟（77%，14/18）有关，原因是异常参数的识别延迟（33%，6/18）和床边超声检查延迟（56%，10/18），以及手术技能不足导致的治疗延迟（56%，10/18）。
在法国，剖宫产术中外科损伤是导致出血相关产妇死亡的一个越来越多的、主要可预防的原因，因为其他导致致命性出血的原因已经变得不那么常见。这些妇女的特征表现为肥胖症、既往剖宫产、第二产程剖宫产和在医疗和外科资源有限的医院分娩的发生率较高，这表明了导致致命后果的解释机制和预防机会。
